Standards for non-invasive methods for gastrointestinal motility: scintigraphy. A position statement from the Gruppo Italiano di Studio Motilità Apparato Digerente (GISMAD)

J-pouch versus Roux-en-Y reconstruction after gastrectomy: functional assessment and quality of life (randomized trial)

Purpose

The aim of this study was to evaluate the quality of life and functional emptying of J-pouch versus Roux-en-Y reconstruction after total gastrectomy for malignancy.

Methods

This study was designed as a prospective, nonblinded, randomized, parallel clinical trial (Trial Number: MN Ostrava, 200604). With informed consent, patients undergoing gastrectomy for malignancy were randomized to J-pouch or Roux-en-Y reconstruction. The time taken for a test semisolid meal labeled with ^99mTc-sulfur colloid to exit the reconstructed parts was measured by dynamic scintigraphy 1 year after resection. Quality of life was measured using the Eypasch questionnaire at the same time as functional emptying assessment. This trial was investigator-initiated.

Results

In all, 72 patients were included into the study. The time taken for the test meal to exit the postgastrectomy reconstruction was 16.5±10.0 minutes (mean ± standard deviation) in the Roux-en-Y group and 89.4±37.8 minutes in the “J-pouch” group; the difference was statistically significant (P<0.001). Emptying of the J-pouch appeared to be a linear decreasing function compared to the exponential pattern seen in the Roux-en-Y group. The quality of life measurement showed scores of 106±18.8 points (mean ± standard deviation) in the Roux-en-Y group compared to 122±22.5 points in the J-pouch group; the difference was statistically significant (P=0.0016). There were no important adverse events.

Conclusion

After total gastrectomy, a J-pouch reconstruction empties more slowly and is associated with higher quality of life compared to Roux-en-Y reconstruction. Whether these two observations have a direct causative link remains unanswered.

Stool consistency, but not frequency, correlates with total gastrointestinal transit time in children

OBJECTIVES

To evaluate the correlation between stool characteristics (consistency and frequency) and gut transit time in children and to determine whether the Bristol Stool Form Scale is a reliable method of assessing intestinal transit rate in children.

STUDY DESIGN

From March 2011 to March 2012, 44 children (25 boys and 19 girls, mean age 7.8 years) with a diagnosis of functional constipation and 36 healthy, nonconstipated children (17 boys and 19 girls, mean age 7.6 years) were enrolled. All participants maintained a 1-week stool diary, recording the time and date of every bowel movement and stool form, and then completed a validated questionnaire on functional constipation according to Rome III criteria. Whole gut transit time (WGTT) was then assessed using the radiopaque markers test.

RESULTS

There was a significant correlation between stool form and WGTT in both constipated and nonconstipated children (correlation coefficient -0.84, P<.001). By contrast, there was no correlation between either stool frequency and WGTT or stool frequency and stool form. Multivariate logistic regression analysis, using WGTT as a dependent variable, showed that the sole variable significantly associated with WGTT was stool form (regression coefficient 2.9, OR 18.4, 95% CI 5.4-62.5, P<.001).

CONCLUSION

In this prospective, observational, case-control study, we show that stool form, as measured by the Bristol Stool Form Scale, rather than stool frequency, correlates with WGTT in both constipated and nonconstipated children.

A new point-of-care portable immunosensor for non-invasive assessment of oro-ileal transit time by oral fluid tauroursodeoxycholate measurement after its oral load

A non-invasive test for oro-ileal transit time (OITT) evaluation was developed, based on the measurement of tauroursodeoxycholic acid (TUDCA) oral fluid concentration profile after its oral administration. Exploiting the fact that TUDCA is actively absorbed only in the ileum, OITT is measured as the time corresponding to TUDCA maximum oral fluid concentration (tmax). To measure oral fluid TUDCA concentration in a point-of-care setting, an ultrasensitive portable immunosensor was developed, based on a competitive chemiluminescent enzyme immunoassay (CL-EIA), using immobilized anti-TUDCA antibody and an ursodeoxycholic acid (UDCA)-peroxidase conjugate as tracer, detected by enhanced chemiluminescence employing a portable charge-coupled device (CCD)-based device. The test was validated in 24 healthy subjects before and after treatment with Loperamide, a drug that increases OITT. The developed CL-EIA was accurate and precise, with a LLOQ of 50 pmol L(-1). The measured OITT for healthy subjects (291 ± 50 min) was fairly well correlated with OITT values obtained by measuring TUDCA in serum (r=0.89). An increased OITT was observed in all the studied subjects after Loperamide treatment. The CL immunosensor can be employed directly in gastroenterology and paediatric units and it can thus represent a new non-invasive simple test for OITT evaluation in a point-of-care setting, with improved diagnostic utility.

Gastrointestinal transit in children with chronic idiopathic constipation

Chronic constipation in children is common and produces significant morbidity. Identification of the site of dysmotility in constipation may determine the cause and permit directed management. Scintigraphy differentiates constipated patients with anorectal hold-up from those with colonic slowing. Adults with colonic slowing demonstrate variation in the site of hold-up. However, in children with colonic slowing, variability in the site of hold-up has not been investigated.

PURPOSE

The current study aimed to characterise colonic transit patterns in 64 children with chronic idiopathic constipation.

METHODS

Scintigraphic images were grouped visually by their transit patterns. Intra-observer variation was assessed. Scintigraphic data were analysed quantitatively.

RESULTS

Visual analysis of scintigraphy studies demonstrated normal transit (11/64), anorectal hold-up (7/64) and slow colonic transit (46/64). Transit characteristics in the slow transit group demonstrated three possible subgroups: pancolonic slowing (28/46), discrete hold-up in the transverse colon (10/46) and abnormal small and large bowel transit (8/46). Kappa testing demonstrated consistent characterisation (k = 0.79). Statistical analysis of scintigraphic data demonstrated highly significant differences from normal (P < 0.001) in the subgroups.

CONCLUSION

Scintigraphy demonstrates three possible transit patterns in children with chronic constipation secondary to slow colonic transit.

Effects of anatomical position on esophageal transit time: A biomagnetic diagnostic technique

AIM: To study the esophageal transit time (ETT) and compare its mean value among three anatomical inclinations of the body; and to analyze the correlation of ETT to body mass index (BMI).

METHODS: A biomagnetic technique was implemented to perform this study: (1) The transit time of a magnetic marker (MM) through the esophagus was measured using two fluxgate sensors placed over the chest of 14 healthy subjects; (2) the ETT was assessed in three anatomical positions (at upright, fowler, and supine positions; 90º, 45º and 0º, respectively).

RESULTS: ANOVA and Tuckey post-hoc tests demonstrated significant differences between ETT mean of the different positions. The ETT means were 5.2 ± 1.1 s, 6.1 ± 1.5 s, and 23.6 ± 9.2 s for 90º, 45º and 0º, respectively. Pearson correlation results were r = -0.716 and P < 0.001 by subjects’ anatomical position, and r = -0.024 and P > 0.05 according the subject’s BMI.

CONCLUSION: We demonstrated that using this biomagnetic technique, it is possible to measure the ETT and the effects of the anatomical position on the ETT.

Loss of interstitial cells of Cajal network in severe idiopathic gastroparesis

AIM: To report a case of severe idiopathic gastroparesis in complete absence of Kit-positive gastric interstitial cells of Cajal (ICC).

METHODS: Gastric tissue from a patient with severe idiopathic gastroparesis unresponsive to medical treatment and requiring surgery was analyzed by conventional histology and immunohistochemistry.

RESULTS: Gastric pacemaker cells expressing Kit receptor had completely disappeared while the local level of stem cell factor, the essential ligand for its development and maintenance, was increased. No signs of cell death were observed in the pacemaker region.

CONCLUSION: These results are consistent with the hypothesis that a lack of Kit expression may lead to impaired functioning of ICC. Total gastrectomy proves to be curative.

Calculating colon transit time withradionuclide-filled capsules in constipated patients: a new method for colon transit study

BACKGROUND

Colon motility disorders require reliable methods for calculating segmental colonic transit time. This study evaluated bowel transit time by means of a safe, easy, cheap, non-digestive, and non-disintegrating radionuclide-filled capsule that provided accurate and clear images.

METHODS

Radionuclide-filled mini-containers (MCs) were prepared from infusion sets by an apparatus used for sealing blood bags or plasmapheresis sets. In vitro stability studies were performed by immersing 5% methylene blue dye-filled MCs in buffers of variable pH and enzymes simulating the conditions in the stomach and the small bowel. Colon transit scintigraphy was performed with MCs filled with iodine 131 (n = 5) and thallium 201 (n = 8) that were placed in a commercially available capsule.

RESULTS

By in vitro acid, base, and intestinal enzyme resistance tests, no methylene blue leakage was determined visually and by spectrophotometric analysis. Accurate and clear images were obtained for colon transit study in constipated patients. After excretion of MCs in the feces, abdominal, myocardial, thyroid, and urinary bladder region counts were found to show the same activity as the background. Radionuclide leakage from MCs was not determined in vivo by gamma camera.

CONCLUSIONS

This is a suitable, safe, easy, and cheap method to provide accurate and clear images for colon transit study in constipated patients.

Pseudo-pseudo-obstruction

Chronic intestinal pseudo-obstruction is a clinical syndrome characterised by symptoms and signs of intestinal obstruction in the absence of a mechanical lesion of the intestinal lumen. The diagnosis is often difficult and relies on clinical, radiological and manometric grounds. We present here a case in which such a diagnosis was suspected, but a thorough in-depth evaluation revealed that the symptoms were due to a treatable cause--abdominopelvic adhesions.

Predictors of gastroparesis in out-patients with secondary and idiopathic upper gastrointestinal symptoms

BACKGROUND

Delayed gastric emptying occurs frequently in patients with upper gastrointestinal symptoms associated with functional or organic diseases.

AIMS

To evaluate whether: (i) the prevalence of delayed gastric emptying is influenced by the presence of organic disease; (ii) demographic or clinical factors predict modestly or markedly (gastroparesis) delayed emptying.

PATIENTS

A total of 327 consecutive out-patients with upper gastrointestinal symptoms.

METHODS

Routine diagnostic work-up and evaluation of demographic factors, gastrointestinal symptom evaluation and scintigraphic gastric emptying of solids were performed.

RESULTS

Organic diseases were detected in 227/327 (65%) patients: 33% had delayed emptying and 20% gastroparesis. Female gender (OR: 2.1; 95% C.I.: 1.3-3.4). overweight (0.5; 0.3-0.9), relevant postprandial fullness (1.8; 1.1-3.2) and relevant epigastric bloating (1.8; 1.1-2.9), but not the presence of organic diseases, were associated with delayed emptying. Female gender (3.9; 1.3-11.9) and relevant postprandial fullness (4.1; 1.7-10.2) were associated with gastroparesis.

CONCLUSIONS

(i) There is a high prevalence of delayed gastric emptying and gastroparesis in out-patients with upper gastrointestinal symptoms, which is not influenced by the presence of organic disease; (ii) female gender, low body weight, relevant fullness and bloating are associated with delayed emptying; female gender and relevant postprandial fullness predict gastroparesis.

Measurement of gastric emptying in gastroesophageal reflux-related chronic cough

STUDY OBJECTIVES

Gastroesophageal reflux (GER) is one of the most common causes of chronic cough, but the mechanisms of GER-related cough are not well-understood. We tested the hypothesis that gastric emptying is delayed in patients with GER-related chronic cough.

DESIGN

We studied 12 patients (7 women; mean age, 53 years; age range, 37 to 68 years) with GER-related chronic cough and a control group of 27 asymptomatic healthy volunteers (16 women; mean age, 37 years; age range, 18 to 62 years). Gastric emptying scintigraphy was performed, and the time at which 50% of the radiolabeled material had left the stomach (T(1/2)) was calculated.

RESULTS

There was no statistically significant difference in T(1/2) values between healthy volunteers and subjects with GER-related cough (99 +/- 26 min vs 86 +/- 20 min, respectively; difference between the means, 13 min [95% confidence interval, -4 to 30 min]; p = 0.13).

CONCLUSIONS

Gastric emptying was not delayed in patients with GER-related chronic cough. The measurement of gastric emptying did not therefore provide further insights into the mechanisms of GER-related cough or clinically relevant information that would assist in patient management.

Gastric emptying and duodeno-gastro-oesophageal reflux in gastro-oesophageal reflux disease

BACKGROUND

Previous studies present conflicting results regarding relationship between gastric emptying and gastro-oesophageal reflux disease. Reflux of duodenal content to oesophagus is generally considered to be associated with more severe disease.

AIM

To assess presence of a gastric emptying disorder in persons with reflux of duodenal contents to oesophagus and to identify any correlation with gastric emptying and oesophageal motility.

METHODOLOGY

A total of 15 subjects with (B+) and 15 subjects without (B-) bile reflux to oesophagus determined by 24-hour bilirubin monitoring were studied with scintigraphic solid gastric emptying and 24-hour oesophageal manometry.

RESULTS

There was no difference in lag phase [median 23.7 (range 10.8-44.0) vs 24.6 (8.1-40.1) min], half emptying time [74.6 (48.0-93.6) vs 82.8 (54.4-153.9) min] or emptying rate [0.89 (0.59-1.34) vs 0.83 (0.36-1. 15)%/min] for B- and B+ subjects, respectively. In addition, there was no difference in emptying rate of gastric fundus between B- and B+ subjects. Subjects with bile reflux had less effective oesophageal contractions of oesophageal body [9.4(3.3-37)%] compared to subjects without bile reflux [32(19-47)%, p = 0.002]. However, there was no correlation between oesophageal motility and gastric emptying.

CONCLUSION

Results suggest that a gastric emptying disorder is a less likely contributing cause of bile reflux to the oesophagus, but bile reflux is associated with less effective oesophageal motility.

Gastric emptying in myotonic dystrophic patients

BACKGROUND

Myotonic dystrophy is often associated with digestive symptoms that can precede the clinical appearance of skeletal muscle involvement. Although motility disorders may be observed in these patients at any level of the gastrointestinal tract, upper gastrointestinal symptoms have up to now usually been considered to be due to oesophageal rather than gastric dysmotility.

AIMS

To evaluate: a) gastric emptying in myotonic dystrophic patients without dyspeptic symptoms, and b) relationship between gastric emptying and severity and duration of the disease.

PATIENTS AND METHODS

Gastric emptying was evaluated in 11 non-dyspeptic dystrophic patients and in 22 healthy volunteers by means of computerised ultrasound scan, assessing the variation in the antral area over time after ingestion of a meal.

RESULTS

The final emptying time was higher in patients than in healthy volunteers (373' +/- 35' vs 270' +/- 47'; p < 0.001). Basal and maximal post-prandial antral areas were similar in the two groups. There was a significant correlation between gastric emptying and the duration of the disease (rs = 0.62; p = 0.04). No relationship was found between gastric emptying and severity of the disease.

CONCLUSIONS

Gastric emptying may be abnormally delayed in myotonic dystrophy patients, even in absence of dyspeptic symptoms. This delay is correlated with duration but not with severity of the disease. However there is no difference in either basal or maximal postprandial antral areas between myotonic dystrophy patients and healthy volunteers.

Novel method to assess gastric emptying in humans: the Pellet Gastric Emptying Test

To further validate the Pellet Gastric Emptying Test (PGET) as a marker of gastric emptying, a randomized, four-way crossover study was conducted with 12 healthy subjects. The study consisted of oral co-administration of enteric coated caffeine (CAFF) and acetaminophen (APAP) pellets in four treatment phases: Same Size (100 kcal), Fasted, Small Liquid Meal (100 kcal), and Standard Meal (847 kcal). The time of first appearance of measurable drug marker in plasma, t(initial), was taken as the emptying time for the markers. Co-administration of same size enteric coated pellets of CAFF and APAP (0.7 mm in diameter) revealed no statistically significant differences in t(initial) values indicating that emptying was dependent only on size and not on chemical make-up of the pellets. Co-administration of different size pellets indicated that the smaller 0.7-mm diameter (CAFF) pellets were emptied and absorbed significantly earlier than the larger 3.6-mm diameter (APAP) pellets with both the Small Liquid Meal (by 35 min) and the Standard Meal (by 33 min) (P<0.05). The differences in emptying of the pellets were not significant in the Fasted Phase. The results suggest that the pellet gastric emptying test could prove useful in monitoring changes in transit times in the fasted and fed states and their impact on drug absorption.

Role of autonomic dysfunction in patients with functional dyspepsia

BACKGROUND

The role of autonomic dysfunction in patients with functional dyspepsia is not completely understood.

AIMS

1. to prospectively assess abnormalities of autonomic function in patients with functional dyspepsia, 2. to assess whether autonomic dysfunction in these patients is associated with a. visceral hypersensitivity or b. delayed gastric emptying or c. severity of dyspeptic symptoms.

PATIENTS

A series of 28 patients with functional dyspepsia and 14 healthy volunteers without gastrointestinal symptoms were studied.

METHODS

All patients and controls were submitted to a battery of five standard cardiovascular autonomic reflex tests, dyspeptic questionnaire, gastric barostat tests and gastric emptying tests.

RESULTS

1. Autonomic function tests showed that both sympathetic and parasympathetic scores of dyspeptic patients were significantly higher than in controls; 2. visceral hypersensitivity was confirmed in dyspeptics in response to proximal gastric distension, demonstrating lower pain threshold; 3. delayed gastric emptying occurred more frequently in patients with functional dyspepsia than in controls; 4. epigastric pain and epigastric burning were significantly more prevalent in patients with definite evidence of autonomic dysfunction; 5. No significant association was found between presence of autonomic dysfunction and presence of visceral hypersensitivity or presence of delayed gastric emptying in patients with functional dyspepsia.

CONCLUSIONS

We concluded that a possible role of autonomic dysfunction in eliciting dyspeptic symptoms could not be determined from alterations in visceral hypersensitivity or delayed gastric emptying. Autonomic dysfunction might not be the major explanation for symptoms associated with functional dyspepsia.